blebectomy – Thoracic Surgery

Living legends and Cirugia de Torax

writing about Dr. Diego Gonzalez Rivas and the other living legends in thoracic surgery and connecting people to the world of thoracic surgery

Readers at Cirugia de Torax have certainly noticed that there are numerous articles regarding the work of Dr. Diego Gonzalez Rivas. This week in particular, after a recent thoracic surgery conference and an afternoon in the operating room – there is a lot to say about the Spanish surgeon.

It’s also hard to escape that fact that I regard him in considerable awe and esteem for his numerous contributions to thoracic surgery and prolific publications. I imagine that this is similar to how many people felt about Drs. Cooley, Pearson or Debakey during their prime.

Making thoracic surgery accessible

But the difference is Dr. Diego Gonzalez Rivas himself. Despite the international fame and critical surgical acclaim, he remains friendly and approachable. He has also been extremely supportive of my work, at a time when not many people in thoracic surgery see the necessity or utility of a nurse-run website.

After all, the internet is filled with other options for readers; CTSnet.org, multiple societies like the Society of Thoracic Surgeons (STS), and massive compilations like journal-based sites (Annals of Thoracic Surgery, Journal of Thoracic Disease, Interactive Journal of Cardiothoracic Surgery).

But the difference between Cirugia de Torax and those sites is like the difference between Dr. Gonzalez Rivas and many of the original masters of surgery: Approach-ability and accessibility.

This site is specifically designed for a wider range of appeal, for both professionals in thoracic surgery, and for our consumers – the patients and their families. Research, innovation, news and development matters to all of us, not just the professionals in the hallowed halls of academia. But sometimes it doesn’t feel that way.

Serving practicing surgeons

For practice-based clinicians, and international surgeons publication in an academia-based journal requires a significant effort. These surgeons usually don’t have research assistants, residents and government grants to support their efforts, collect their data and clean up their grammar. Often English is a second or third language. But that doesn’t mean that they don’t make valuable contributions to their patients and the practice of thoracic surgery. This is their platform, to bring their efforts to their peers and the world.

Heady aspirations

That may sound like a lofty goal, but we have readers from over a 110 countries, with hundreds of subscribers along with over 6,000 people with Cirugia de Torax directly on their smart phone. Each month, we attract more hits and more readers.

Patient-focused information

That’s important for the other half of our mission – connecting our patients with the world of thoracic surgery. Discussing research findings, describing procedures and presenting information to the people who are actually undergoing the procedures we are writing about. Letting them know what’s new, what’s changed – and what to expect.

Every day, at least 200 people read “Blebs, Bullae and Spontanous Pneumothorax”. Why? Because it’s a concise article that explains what blebs are, how a pneumothorax occurs and how it’s treated. Another hundred people usually go on to read the accompanying case report about blebectomy, for similar reasons. There are links for more information, CT scans and intra-operative photos included, so that people can find exactly what they need with a minimum of effort.

Avoiding ‘Google overload’

With the massive volume of information available on the internet, high-quality, easily understood, applicable information has actually become even more difficult for patients to find than ever before. Patients spend hours upon hours browsing through academic jargon, commercial websites and biased materials while attempting to sift through the reams of information for pertinent and easily understandable information. There is also a lot of great material out there – so we provide links to reputable sites, recommend well-written articles and discuss related research.

Connecting patients to surgeons

We also provide patients with more information about the people they are entrusting their bodies, their hopes and their lives to. It’s important that they know about the Dr. Benny Wekslers, the Dr. Hanao Chens, and the Dr. Diego Gonzalez Rivas out there.

Update: June 2019

After multiple reader requests from this site, we have launched a service to assist readers in pursuiting minimally invasive thoracic surgery, uniportal surgery, HITHOC and other state-of-the-art thoracic surgery procedures with the modern masters of thoracic surgery. We won’t talk a lot about this on the site, but we do want readers to know that we are here to help you. If you are wondering what surgery costs like with one of the world’s experts – it’s often surprisingly affordable.

If you are interested in knowing more, please head to our sister site, www.americanphysiciansnetwork.org or send an email to kristin@americanphysiciansnetwork.org.

Keeping it ‘real’

Looking over the shoulder of Dr. Gonzalez Rivas in the operating room

As much as I may admire the work and the accomplishments of Dr. Gonzalez-Rivas – it’s important not to place him on a pedestal. He and his colleagues are real, practicing surgeons who operating on regular people, not just heads of state and celebrities. So when we interview these surgeons and head to the OR, it’s time to forget about the accolades, the published papers and the fancy titles. It’s time to focus on the operations, the techniques, the patients and the outcomes because ‘master of thoracic surgery’ or rural surgeon – the operation and patient are all that really matters.

K. Eckland

Post operative pain after thoracic surgery

What kind of pain should patients expect after thoracic surgery, and how long will it last? Also, is this normal? When should I call my doctor?

Like all posts here at Cirugia de Torax, this should serve as a guide for talking to your healthcare provider, and is not a substitute for medical advice.

Quite a few people have written in with questions about post-operative pain after thoracic surgery procedures so we will try to address those questions here.

1. What is a normal amount of pain after these procedures?

While no two people will experience pain the same, there are some general guidelines to consider. But to talk about this issue – we will need to refer to a basic pain scale which rates pain from 0 (no pain) to 10 – (excruciating, writhing pain, worst possible imaginable).

Unfortunately, for the majority of people who have thoracic surgery, there will be some pain and discomfort.

Pain depends on the procedure

In general, the intensity and duration of pain after thoracic procedures is related to the surgical approach – or the type of surgical incision used.

open thoracotomy,empyema, advanced with extensive purulence — This open incision (with rib spreading) will hurt more..
Photo: advanced empyema requiring open thoracotomy for decortication

Pain will be much less with a single incision VATS surgery (now with chest tube) and specimen removed (photo courtesy of Dr. Chen)

Patients with larger incisions like a sternotomy, thoracotomy or clamshell incision will have more pain, for a longer period of time than patients that have minimally invasive procedures like VATS because there is more trauma to the surrounding tissues. People with larger incisions (from ‘open surgeries’) are also more likely to develop neuralgia symptoms as they recover.

. (I will post pictures of the various incisions once I return home to my collection of surgical images).

Many patients will require narcotics or strong analgesics for the first few days but most surgeons will try to transition patients to anti-inflammatories after surgery.

Post-operative surgical pain is often related to inflammation and surgical manipulation of the chest wall, particularly in procedures such as pleurodesis, decortication or pleurectomy. For many patients this pain will diminish gradually over time – but lasts about 4 to 6 weeks.

Anti-inflammatories

This pain is often better managed with over the counter medications such as ibuprofen than with stronger narcotics. That’s because the medication helps to relieve the inflammation in addition to relieving pain. Anti-inflammatory medications also avoid the risks of oversedation, drowsiness and severe constipation that often comes with narcotics.

Use with caution

However, even though these medications are available without a prescription be sure to talk to your local pharmacist about dosing because these medications can damage the kidneys. Also, be sure to keep hydrated while taking this medications.

People with high blood pressure should be particularly cautious when taking over the counter anti-inflammatories because many of these medications have drug interactions with blood pressure medications.

2. “I had surgery three weeks ago, and I recently developed a burning sensation near the incision”

Neuralgias after surgery

For many patients, the development of a neuralgia is a temporary effect and is part of the healing process. However, it can be quite disturbing if patients are unprepared. Neuralgic pain is often described as a burning or stinging sensation that extends across the chest wall from the initial incision area. Patients also describe it as a ‘pins and needles’ sensation or “like when your foot falls asleep”. This usually develops a few weeks after surgery as the nerves heal from the surgery itself.

It the discomfort is unmanageable, or persists beyond a few weeks, a return visit to your surgeon is warranted. He/She can prescribe medications like gabapentin which will soothe the irritated nerves and lessen the sensations. However, these medications may take some time to reach full effect.

Range of motion and exercise after surgery

Exercise limitations are related to the type of incision.

Sternotomy incisions/ sternotomy precautions

If you have a sternotomy incision – (an incision through the breast bone at the center of your chest), this incision requires strict precautions to prevent re-injury to the area. Since the sternal bone was cut, patients are usually restricted from lifting anything greater than 10 pounds for 6 to 12 weeks, and to avoid pushing, pulling or placing stress on the incision. Patients are also restricted from driving until bone healing is well underway. (Be sure to attend a rehab program or physical therapy program to learn the proper way to exercise during this time period).

Patients will also need to take care to prevent a surgical skin infection or something more serious like mediastinitis. The includes prohibitions against tub bathing/ soaking, swimming or over- aggressive cleaning of the incision with harsh abrasives like hydrogen peroxide or anti-bacterial soaps. These chemicals actually do more harm than good in most cases by destroying the newly healing tissue. A good rule of thumb to remember (unless your doctor says otherwise): No creams or lotions to your incisions until the scabs fall off.

Post-thoracotomy incisions

With a large thoracotomy incision, most patients will be restricted from lifting any items greater than 10 pounds on the surgery side for around two weeks. However, unlike sternotomy patients – we want you to use and exercise that arm daily – otherwise patients have a risk of developing a ‘disuse’ syndrome. One of the common exercises after a thoracotomy is called the spider crawl. This exercise helps the muscles to heal and prevent long-term disability or problems. The physiotherapist at your local hospital should have a list of several others that they can teach you to practice at home.

The spider crawl

In this example, the patient had a left thoracotomy:

1. Stand with your surgical side within arm’s length of the wall.

Now, use your hand to “walk” up the wall, similar to a spider crawling.

'walking' the hand up the wall — ‘walking’ the hand up the wall

Continue to walk your hand up the wall until your arm is fully extended.

Perform this exercise (or similar ones) for several minutes 5-6 times a day. As you can see – it is fast and easy to do.

VATS

For patients with minimally invasive procedures – there are very few exercise restrictions, except no heavy lifting for 2 to 3 weeks (this is not the time to help your neighbor move his television.)

General incision care guidelines are similar to that for sternotomy patients – no soaking or bathing (showering is usually okay), no creams or lotions and no anti-bacterial soaps/ hydrogen peroxide/ harsh cleaners.

Whats NOT normal – when it’s time to call your surgeon

– dramatic increase in pain not associated with activity (i.e. lifting or reaching). If your pain has been a “4” for several days and suddenly increases to an “8”

– If the quality of the pain changes – ie. if it was a dull ache and becomes a stabbing pain.

– any breathlessness, shortness of breath or difficulty breathing

– Any increase in redness, or swelling around your incisions. Incisions may be pink and swollen for the first 2-3 days, but any increase after that warrants a ‘wound check’ by your surgeon

– Any fresh bleeding – bright red blood. A small amount of drainage (from chest tube sites) that is light pink, clear or yellow in nature may be normal for the first few days.

– Drainage from the other sites (not chest tube sites) such as your primary incision is not normal and may be a sign of a developing infection.

– Fever, particularly fever greater than 101.5 – may be a sign of an infection.

– If you are diabetic, and your blood sugars become elevated at home, this may also be a sign of infection. (Elevation in the first few days is normal, and is often treated with insulin – particularly if you are in the hospital.

– Pain that persists beyond 3 months may be a sign of nerve damage (and you will need additional medications / therapies).

In the operating room with Dr. Mauricio Velaquez: Single port thoracoscopy

a day in the operating room with one of Colombia’s New Masters of Thoracic Surgery

Cali, Colombia

Dr. Mauricio Velasquez is probably one of the most famous thoracic surgeons that you’ve never heard of. His thoracic surgery program at the internationally ranked Fundacion Valle del Lili in Cali, Colombia is one of just a handful of programs in the world to offer single port thoracic surgery. Dr. Velasquez has also single-handedly created a surgical registry for thoracic surgeons all over Colombia and recently gave a presentation on the registry at a national conference. This registry allows surgeons to track their surgical data and outcomes, in order to create specifically targeted programs for continued innovation and improvement in surgery (similar to the STS database for American surgeons).

Mauricio Velasquez, thoracic surgeon — Dr. Mauricio Velasquez after another successful case

Dr. Velasquez is also part of a team at Fundacion Valle del Lili which aims to add lung transplant to the repertoire of services available to the citizens of Cali and surrounding communities.

He is friendly, and enthusiastic about his work but humble and apparently unaware of his growing reputation as one of Colombia’s finest surgeons.

Education and training

After completing medical school at Universidad Pontificia Bolivariana in Medellin in 1997, he completed his general surgery residency at the Universidad del Valle in 2006, followed by his thoracic surgery fellowship at El Bosque in Bogotá.

The Colombia native has also trained with thoracic surgery greats such as Dr. Thomas D’Amico at Duke University in Durham, North Carolina, and single port surgery pioneer, Dr. Diego Gonzalez Rivas in Coruna, Spain. He is also planning to receive additional training in lung transplantation at the Cleveland Clinic, in Cleveland, Ohio this summer.

Single port surgery

Presently, Dr. Velasquez is just one of a very small handful of surgeons performing single port surgery. This surgery is an adaptation of a type of minimally invasive surgery called video-assisted thoracoscopy. This technique allows Dr. Velasquez to perform complex thoracic surgery techniques such as lobectomies and lung resections for lung cancer through a small 2 – 3 cm incision. Previously, surgeons performed these operations using either three small incisions or one large (10 to 20cm) incision called a thoracotomy.

By using a tiny single incision, much of the trauma, pain and lengthy hospitalization of a major lung surgery are avoided. Patients are able to recovery and return to their lives much sooner. The small incision size, and lack of rib spreading means less pain, less dependence on narcotics and a reduced incidence of post-operative pneumonia and other complications caused by prolonged immobilization and poor inspiratory effort.

However, this procedure is not just limited to the treatment of lung cancer, but can also be used to treat lung infections such as empyema, and large mediastinal masses or tumors like thymomas and thyroid cancers.

Team approach

Part of his success in due in no small part to Dr. Velasquez’s surgical skill, another important asset to his surgical practice is his wife, Dr. Indira Cujiño, an anesthesiologist specializing in thoracic anesthesia. She trained for an additional year in Spain, in order to be able to provide specialized anesthesia for her husband’s patients, including in special circumstances, conscious sedation. This allows her husband to operate on critically ill patients who cannot tolerate general anesthesia. While Dr. Cujiño does not perform anesthesia for all of Dr. Velasquez’s cases, she is always available for the more complex cases or more critically ill patients.

In the operating room with Dr. Velasquez

I spent the day in the operating room with Dr. Velasquez for several cases and was immediate struck by the ease and adeptness of the single port approach. (While I’ve written quite a bit about the literature and surgeons using this technique, prior to this, I’ve had only limited exposure to the technique intra-operatively.) Visibility and maneuverability of surgical instruments was vastly superior to multi-port approaches. The technique also had the advantage that it added no time, or complexity to the procedure (unlike robotic surgery).

OLYMPUS DIGITAL CAMERA — Dr. Velasquez performing single port thoracoscopy

Cases proceeded rapidly; with no complications.

Note to readers – some of the content, and information obtained during interviews, conversations etc. with Dr. Velasquez may be used on additional websites aimed at Colombia-based readers.

Recent Publications

Zarama V, Velásquez M. (2012). Mainstem Bronchus Transection after Blunt Chest Trauma. J Emerg Med. 2012 Feb 3.

Dual port VATS for recurrent spontaneous pneumothorax: Foroulis et. al

A newly published study comparing dual port thoracoscopy with mini-thoracotomy for the treatment of recurrent spontaneous pneumothorax

Here at cirugia de torax, we take a keen interest in the development of increasingly minimally invasive technologies from dual (and single-port) thoracoscopy for a variety of conditions to RATS (robot- assisted thoracic surgery). It is our belief that by embracing these emerging technologies, we help to advance the thoracic surgery specialty.

This spring, we have had the pleasure of publishing case reports on dual port thoracoscopy for decortication of parapneumonic effusions and empyema and catching up with one of the leaders in single incision thoracic surgery, Dr. Diego Gonzalez Rivas.

This month, another entry, “A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study,” by Dr. Christophoros N. Foroulis at the Aristotle Medical School in Thessaloniki, Greece was published in Surgical Endoscopy. As noted in a previous post, there have been few (if any) published papers on dual port thoracoscopy, and no comparison studies of these two techniques.

This study, which was conducted during 2006 to 2009 followed 66 patients who were randomly assigned to receive either mini-thoracotomy or dual-port VATS for surgical pleurodesis/ bullectomy / blebectomy.

In this study, despite random assignment, each group of 33 patients were well matched in all characteristics such as age, operative side and BMI. After surgical treatment, patients were followed for a median of 30 months (range 3 – 53 months) for development of late complications or recurrent pneumothorax.

Each treatment group – VATS versus open surgical was overseen by one surgeon with Dr. Foroulis performing all of the dual port surgeries, and Dr. Papakonstantinou performing all of the open procedures. Outcomes were independently reviewed / evaluated by the remaining authors.

Study Findings

– No conversions to open thoracotomy from the VATS group.

– Similar rate of recurrence between open (2.7%) and VATS (3%) group (but timing of recurrence differed.) Both recurrent pneumothoraces in the VATS group occurred early post-operatively (POD#5) compared to the open surgical group – 13 months post-op.

– Rate of complications the same between groups but the type of complications differed. 2 patients in each group required reoperation:

VATS – reoperation for prolonged airleak

Minithoracotomy group – hematomas/ evacuation of clots

Length of stay (LOS) and post-operative pain

Surprisingly, length of stay and post-operative pain – two of the outcomes that are usually cited in favor of minimally invasive procedures – were not significantly different between the groups.

Differences

Patient satisfaction

However, patient satisfaction was significantly higher in the dual port group. This was related to an earlier return to normal activities, and earlier full mobilization of the affected arm.

Longer procedures

VATS procedures were longer than open procedures – by a mean of 21 minutes (87.1 minutes for VATS versus 66.7 minutes for minithoracotomy) with associated increases in uni-lung ventilation time.

Discussion/ Conclusions

While previous studies had reported a recurrence rate that was significantly higher in the VATS group – that was not seen here. The ability to detect blebs/ bullae (and thus treat) with VATS remains limited in comparison to a mini-thoracotomy, but does not appear to change outcomes after a successful pleurodesis procedure. Dual port thoracoscopy does take more time but both procedures appear equally effective.

Reference:

Foroulis, C. N., Anastasiadis, K., Charokopos, N., Antonitisis, P., Halvatzoulis, H. V., Karapanagiotidis, G. T., Grosomanidis, V. & Papakonstantinou, C. (2012). A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study. Surg Endosc 2012 May 12. Includes color photographs of procedures.

Thank you to Dr. Foroulis for your assistance.

For more on related topics:

Case study: spontaneous pneumothorax

About spontaneous pneumothorax

Minimally invasive surgery: SITS

Blebs, Bullae and Spontaneous Pneumothorax

Overview of spontaneus pneumothorax and treatment modalities.

There are multiple classifications of pneumothoraces – primary, secondary, iatrogenic, traumatic, tension etc. This article is a limited overview of the most common type(s) of pneumothorax, and methods of treatment.

What are blebs?

The lung is made up of lung tissue itself (consisting of alveoli, bronchi and bronchioles) and a thin, membranous covering called the pleura. This covering serves to prevent inhaled air from travelling from the lung to the area inside the thoracic cavity. ‘Blebs’ are blister-like air pockets that form on the surface of the lung. Bulla (or Bullae for pleural) is the term used for air-filled cavities within the lung tissue.

Who gets/ who has blebs and/or bullae?

Blebs and bullae may be related to an underlying disease process such as emphysema / chronic obstructive pulmonary disease, but they (blebs in particular) may also be found in young, healthy people with no other medical issues. Indeed, the ‘classic’ scenario for a primary spontaneous pneumothorax is a young adult male (18 – 20’s), tall and thin in appearance and no other known medical history who presents with complaints of shortness of breath or dyspnea.

Smoking, and smoking cannabis have been implicated in the development of spontaneous pneumothorax in young (otherwise healthy) patients.

Bullae, or air pockets within the lung tissue are more commonly associated with chronic disease processes such as chronic obstructive pulmonary disease (emphysema). It can be also part of the clinical picture in cystic fibrosis and other lung diseases.

How do blebs cause a pneumothorax?

When these blebs rupture or ‘pop’ inhaled air is able to travel from the airways to the thoracic cavity, creating a pneumothorax or lung collapse.

The symptoms of a pneumothorax depend on the amount of lung collapse and the baseline respiratory status of the patient. In young, otherwise healthy patients, the symptoms may be more subtle even with a large pneumothorax. In patients with limited reserve (chronic smokers, COPD, pulmonary fibrosis, sarcoidosis) patients may experience shortness of breath, dyspnea/ difficulty breathing, chest and chest wall pain. With large pneumothoraces or complete collapse of a lung, patients may become cyanotic, or develop respiratory distress.

In cases of pneumothorax caused by external puncture of the lung, or other traumatic circumstances, a patient may develop a life-threatening condition from a tension pneumothorax. This can happen with a simple, primary lung collapse from bleb rupture, but it is uncommon.

How is this treated?

Simple (or first-time) pneumothorax

Oxygen therapy – traditional treatment for small pneumothorax in asymptomatic or minimally symptomatic patients was oxygen via a face mask or non-rebreather. Much of the more recent literature has discredited this as an effective treatment.

Tube thoracostomy (aka chest tube placement) – a chest tube is placed to evacuate air from the thoracic cavity, to allow the lung to re-expand. The chest tube is initially placed to suction until the lung surface heals, and the lung is fully expanded. After a waterseal trial, the chest tube is removed.

Recurrent pneumothorax / other circumstances;

Blebectomy via:

VATS (video-assisted thoracoscopy)
Open thoracotomy or mini-thoracotomy

As we have discussed previously, the VATS procedure / open thoracotomy and mini-thoracotomy are not really stand alone procedures but are the surgical approaches or techniques used to gain entry into the chest. Using a VATS technique involves the creation of one or more ‘ports’ or opening for the use of thoracoscopic surgical tools, and a thoracoscope (or camera.) There are rigid and flexible scopes available; but most thoracic surgeons prefer the rigid scopes for better visibility and control of tissue during the operation[1].

VATS photo — blebs seen during VATS procedure

Open thoracotomy or mini-thoracotomy incisions may be used to gain access to the lung, particularly for resection of bullae (lung volume reduction) surgeries for the treatment of chronic disease.

During this procedure, fibrin sealants may be used. Investigational use of both radio-frequency and other ablative therapies have also been used (Linchevskyy, Makarov & Getman, 2010, Funai, Suzuki, Shimizu & Shiiya 2011**).

Treatment Guidelines

British Thoracic Surgeons 2010 treatment guidelines

American College of Chest Physicians – a bit dated (2001)

Linchevskyy, Makarov & Getman, 2010. Lung sealing using the tissue-welding technology in spontaneous pneumothorax. Eur J Cardiothorac Surg (2010) 37(5): 1126-1128.

Funai, Suzuki, Shimizu & Shiiya (2011). Ablation of weak emphysematous visceral pleura by an ultrasonically activated device for spontaneous pneumothorax. Interact CardioVasc Thorac Surg (2011) 12(6): 908-911.

Pleurodesis may also be used – in combination with either tube thoracostomy or surgical resection. Pleurodesis can be performed either mechanically, chemically or both. Mechanical pleurodesis is accomplished by irritated the pleura by physical means (such as scratching or rubbing the pleura with the bovie scratch pad or surgical brushes. A chest tube also produces a small amount of mechanical pleurodesis as the tube rubs on the chest wall during patient movement.

Chemical pleurodesis is the instillation of either sterile talc or erythromycin to produce irritation or inflammation of the pleura. With bedside pleurodesis or tube thoracostomy pleurodesis, sterile talc is mixed with lidocaine and sterile water to create a talc slurry. (If you like your patient, carry it in your pocket for 10 – 20 minutes to allow the solution to warm to at least room temperature. This will help reduce the discomfort during instillation.) The mixture should be in a 60cc syringe or similar delivery device – shake briskly before use. The mixture is then instilled via the existing thoracostomy tube. The chest tube is clamped for 30 – 60 minutes (dwell time) and the patient is re-positioned every 10 to 20 minutes. Despite the lidocaine, the talc will produce a burning sensation, so pre-medication is desirable. This procedure has largely fallen out of fashion in many facilities. Post-pleurodesis, pleural inflammation may cause a brief temperature elevation. This is best treated with incentive spirometry, and pulmonary toileting.

Chemical pleurodesis can also be performed in the operating room. Loose sterile talc can be insufflated, or instilled using multiple delivery devices including aerosolized talc. As discussed in previous articles, pleurodesis can also be used for the treatment of pleural effusions.

Sepehripour, Nasir and Shah (2011). Does mechanical pleurodesis result in better outcomes than chemical pleurodesis for recurrent primary spontaneous pneumothorax? Interact CardioVasc Thorac Surg ivr094 first published online December 18, 2011 doi:10.1093/icvts/ivr094

Alayouty, Hasan, Alhadad Omar Barabba (2011). Mechanical versus chemical pleurodesis for management of primary spontaneous pneumothorax evaluated with thoracic echography. Interact CardioVasc Thorac Surg (2011) 13(5): 475-479

Special conditions and circumstances related to Pneumothorax:

Catamenial pneumothorax – this a pneumothorax that occurs in menstruating women. It usually occurs on the right-side and is associated with endometriosis, and defects in the diaphragm. A related case study can be viewed here. Several recent studies suggest catamenial pneumothorax may be more common that previously believed and should be suspected in all women presenting with right-sided pneumothorax, particularly if pneumothorax occurs within 48 – 72 hours of menstrual cycle. This may be the first indication of underlying endometrial disease.

Additional References

For more reference citations and articles about the less common causes – see More Blebs, Bullae and Spontaneous Pneumothorax

Pneumothorax: an update – gives a nice overview of the different types of pneumothorax, and causes of each.

Medscape overview of pneumothorax – this is a good article with radiographs with basic information about pneumothoraces.

More on the difference between blebs and bullae – from learning radiology.com

Lung resection for bullous emphysema

Japanese study suggesting Fibulin-5 protein deficiency in young people with pneumothoraces.

VATS versus tube thoracostomy for spontaneous pneumothorax

What’s worse than a spontaneous pneumothorax? Bilateral pneumothoraces – a case report.

Early article suggesting VATS for treatment of spontaneous pneumothorax (1997)

Blebs, Pneumothorax and chest drains

[1] Flexible scopes are usually preferred for GI procedures such as colonoscopy, where the camera is inserted into a soft tissue orifice. By comparison, the thoracic cavity with the bony rib cage is more easily navigated with the use of a firm instrument.

** I have contacted the primary authors on both of these papers for more information.

Like all materials presented on this site, this paper is presented for information only. It should not be considered medical advice or treatment. Also, all information provided is generalized information and (outside of clinical case presentations) is not intended to treat of diagnose any disease or condition. If you have questions about the content, please contact us. If you have medical questions, please consult your thoracic surgeon or pulmonologist.

Case report: Blebectomy with talc pleurodesis after spontaneous pneumothorax

Case report of spontaneous pneumothorax followed by bleb resection and talc pleurodesis.

During my various travels and interviews, I have had the opportunity to meet and talk with thoracic patients from around the world. During a recent trip, I encountered a very nice young woman (in her early 20’s**). This is her story below:

The patient, the aforementioned young woman had no significant past medical history. She initially presented to a small tertiary facility with chest pain. She was evaluated for acute coronary syndrome and discharged from the emergency department. She subsequently miscarried an early pregnancy.

Several days later, her symptoms intensified, and she became short-of-breath so she returned to the emergency department. On chest radiograph, she was found to have a large left-sided pneumothorax. A chest tube was placed but subsequent radiographs showed a persistent pneumothorax. The nearest trauma facility was notified and the patient was transferred for further evaluation and treatment.

On arrival, the patient who was experiencing significant chest and LUQ pain, and breathlessness received a second chest tube. Following chest tube placement in the emergency room, chest radiograph showed the pneumothorax to be unchanged. The patient was admitted to the hospital for further testing.

A CT scan (TAC) of the chest showing chest tubes in good position and several large blebs. Following the CT scan, thoracic surgery was consulted for further treatment and management.

After discussing the risks, benefits and alternatives with the patient and family, the patient elected to proceed with a left-sided VATS (video-assisted thoracoscopic surgery) with blebectomy and talc pleurodesis.

Patient received pre-operative low dose beta blockade for sinus tachycardia. Patient was intubated with a double lumen ETT for uni-lung ventilation. The patient was hemodynamically stable intra-operatively, and the case proceed without incidence.

Intra-operative thoracoscopy confirmed the presence of several blebs including a large bleb in the left lower lobe. These were resected surgically with noncoated endoGIA staples. (Coated coviden staples have been implicated in several injuries and fatalities previously.)

12 grams of sterile talc was insufflated using an aerosolized technique. A new chest tube was placed at the conclusion of the case. There was minimal to no operative blood loss.

During VATS — surgeon performing video-assisted thoracoscopy

The patient was awakened, extubated and transferred to the post-operative recovery unit. Chest radiograph in recovery showed the lung to be well expanded on -20cm of suction.

Post-operatively the patient had a small airleak. She was maintained on suction for 48 hours and watersealed. Waterseal trials were successful, and on post-operative day #4, chest tube was removed. Subsequent chest x-ray was negative for pneumothorax. Patient was discharged home with a follow-up appointment and a referral to OB-GYN for additional follow-up.

Discussion: Due to patient’s history of miscarriage in close proximity to first reports of chest pain, special consideration was given to the possibility of catamenial pneumothorax (though this was first instance, and on the left whereas 90% of reported cases occur on the right.) While the literature reports previous episodes of pneumothorax during pregnancy, these reports occurred in later gestation (37 and 40 weeks, respectively.) On further evaluation, patient had no history of abnormal vaginal bleeding, pelvic infections, pelvic inflammatory disease or a previous diagnosis of endometriosis. Thoracoscopic evaluation was negative for the presence of endometrial tissue, and there were no diaphragmatic defects.

Final pathology: no abnormal results, confirming intra-operative findings.

**Note: Since this is a blog, available for public viewing, patient permission was obtained prior to posting. All efforts are made to protect patient privacy, and thus details regarding patient demographics have been changed/ omitted. Also, our gracious thanks to the patient and family for allowing this discussion of the case. If you have an interesting, educational or informative case, contact Cirugia de Torax for publication.

For additional information and discussion on blebs and bullae, see our related post here.

Additional information and articles on catamenial pneumothorax:

Majak P, Langebrekke A, Hagen OM, Qvigstad E. Catamenial pneumothorax, clinical manifestations–a multidisciplinary challenge. Pneumonol Alergol Pol. 2011;79(5):347-50.

Ciriaco P, Negri G, Libretti L, Carretta A, Melloni G, Casiraghi M, Bandiera A, Zannini P. Surgical treatment of catamenial pneumothorax: a single centre experience. Interact Cardiovasc Thorac Surg. 2009 Mar;8(3):349-52. Epub 2008 Dec 16.

Sánchez-Lorente D, Gómez-Caro A, García Reina S, Maria Gimferrer J. Treatment of catamenial pneumothorax with diaphragmatic defects. Arch Bronconeumol. 2009 Aug;45(8):414-5; author reply 415-6. Epub 2009 Apr 29. Spanish.

Alifano M, Jablonski C, Kadiri H, Falcoz P, Gompel A, Camilleri-Broet S, Regnard JF. Catamenial and noncatamenial, endometriosis-related or nonendometriosis-related pneumothorax referred for surgery. Am J Respir Crit Care Med. 2007 Nov 15;176(10):1048-53. Epub 2007 Jul 12

Kronauer CM. Images in clinical medicine. Catamenial pneumothorax. N Engl J Med. 2006 Sep 7;355(10):e9

Marshall MB, Ahmed Z, Kucharczuk JC, Kaiser LR, Shrager JB. Catamenial pneumothorax: optimal hormonal and surgical management. Eur J Cardiothorac Surg. 2005 Apr;27(4):662-6